Download - Fluid&electrolyte balance
FLUID,ELECTROLYTE AND ACID FLUID,ELECTROLYTE AND ACID FLUID,ELECTROLYTE AND ACID FLUID,ELECTROLYTE AND ACID
BASE BALANCEBASE BALANCEBASE BALANCEBASE BALANCE
FLUID,ELECTROLYTE AND ACID BASE BALANCE
� FLUID IN TAKE :
1) EXOGENOUS – 2 to 3 Litres /24 Hours
WATER REQUIREMENTS OF INFANTS AND CHILDREN ARE RELATIVELY GREATER THAN THOSE OF ADULTS BECAUSE OF
� THE LARGER SURFACE AREA PER UNIT OF BODY WEIGHT THE GREATER METABOLIC ACTIVITY DUE TO GROWTH � THE COMPARATIVELY POOR CONCENTRATING ABILITY OF THE IMMATURE
KIDNEY 2) ENDOGENOUS - Normally Less than 500ml/24 Hour. IT IS RELEASED DURING THE OXIDATION OF INGESTED FOOD. HOWEVER DURING STARVATION,THIS AMOUNT IS SUPLEMENTED BY
WATER RELEASED FROM THE BREAKDOWN OF BODY TISSUES.
FLUID OUT PUT :
LUNGS – 400ml / 24 Hours SKIN – 600ml to 1000ml / 24Hrs FAECES – 60 to 150ml / 24 Hrs URINE – Approx.1500ml 24Hrs
OLIGURIA – >300 ml / 24 Hours ANURIA – Complete absence of Urine
WATER DEPLETION : DIMINSHED INTAKE
PURE WATER DEPLETION
� CLINICAL FEATURES :
WEAKNESS,INTENSE THIRST, SUNKEN EYES, DRY MUCUS MEMBRANES,DECREASED URINE OUTPUT, LOW PULSE PRESSURE, LOW B.P., CONFUSION.
CVP – Normal 3-8 cm H2O.
�TREATMENT : USING NS OR 5%D SOLUTIONS OR APPROPRIATE WATER REPLACEMENT FORMULAS.
WATER INTOXICATION
� TURP SYNDROME � SIADH : SYNDROME OF INAPPROPIATE ANTIDIURETIC
HORMONE SECRETION � COLORECTAL WASH OUTS WITH PLAIN WATER INSTEAD OF
SALINE CLINICAL FEATURES : DROWSINESS, WEAKNESS,
CONVULSIONS AND COMA. NAUSEA AND VOMITING OF CLEAR FLUID, PASSING LARGE
AMOUNT OF DILUTE URINE. � TREATMENT : STOP INTAKE OF WATER.TRANSFER TO ICU.
TREAT WITH DIURETICS OR HYPERTONIC SALINE. � RAPID CHANGES IN SERUM SODIUM CONCENTRATION –
NEURONAL DEMYELINATION.
WATER BALANCE OF A HEALTHY ADULT(70kg)
INTAKE:
WATER FROM BEVERAGE=1200ml
WATER FROM SOLID FOOD=1000ml
WATER FROM OXIDATION=300ml
OUTPUT:
URINE – 1500ml
SKIN – 500ml
INSENSIBLE LOSS
LUNGS – 400ml
FAECES – 100ml
NORMAL VALUES OF SERUM ELECTROLYES
Na+ - 133 to 144mmol/L
K+ - 3.5 to 5.3mmol/L
Cl- - 90 to 110mmol/L
HCO3- -25mmol/L
Ca+ 8 to 10mg/dl.
SODIUM BALANCE
� SODIUM – PRINCIPAL CATION OF ECF. NORMAL VALUE (SERUM) 133-144 mmol/L
� DAILY INTAKE – AVERAGE 1mmol/kg Nacl or 500ml ISOTONIC 0.9% SALINE SOLUTION.
� CONTROL BY ADRENAL GLANDS.
HYPONATREMIA
SERUM SODIUM < 120mmol/L
CAUSES : BOWEL OBSTRUCTION
FISTULAE VOMITING DIARRHOEA.
CLINICAL FEATURES : CONFUSION, LETHARGY, DISORIENTATION
SEVERE(<120 mmol/L)-SEIZURES, COMA.
TREATMENT
HYPOVOLEMIC HYPONATREMIA :
1) GI FLUID OR BLOOD LOSS - REPLACE VOLUME USING
A CRYSTALLOID(0.9%NaCl or RL) OR A COLLOID.
HYPERVOLEMIC HYPONATREMIA :
1) CHF, CIRROHSIS,NEPHROTIC SYNDROME 2) TREAT THE DISORDER 3) Na RESTRICTION 4) DIURETUICS+WATER RESTRICTION
EUVOLEMIC HYPONATREMIA
1) SIADH
2) WATER RESTRICTION TO <1L/day.
RULE OF THUMB : 1. LIMIT THE CHANGE 1mmol/L OF SODIUM TO HALF OF THE
TOTAL DIFFERENCE IN THE FIRST 24 HRS.
2. RELATIVELY SLOW CORRECTION 0.5mmol/L PER Hour.
RAPID CORRECTION – PONTINE DEMYELINATION.
HYPERNATREMIA CAUSES :
� EUVOLEMIC HYPERNATREMIA (PURE WATER LOSS) SWEATING,FEVER,TACHYPNOEA, DIABETES INSIPIDUS.
� HYPOVOLEMIC HYPERNATREMIA (WATER DEFECIET IN EXCESS OF SODIUM DEFECIET) BURNS, FISTULAS
� HYPERVOLEMIC HYPERNATREMIA (SODIUM GAIN IN EXCESS OF WATER GAIN) EXCESSIVE 0.9% SALINE ADMINISTRATION,ADRENAL HYPER
FUNCTION.
CLINICAL FEATURES SIGNS:
PUFFINES OF THE FACE. PITTING OEDEMA – SACRAL REGION, 4.5 Litres OF EXCESS FLUID.
TREATMENT : HYPOVOLEMIC HYPERNATREMIA RESTORE ECF VOLUME BY 5%D OR 0.45%NS HYPERVOLEMIC HYPERNATREMIA DIURETICS DIALYSIS IN PRESENCE OF RENAL FAILURE EUVOLEMIC HYPERNATREMIA WATER REPLACEMENT WITH 5%D
POTASSIUM BALANCE
� POTASSIUM : NORMAL RANGE 3.5 – 5.3 mmol /L POTASSIUM IS ALMOST
ENTIRLY INTRACELLULAR(98%) NORMAL ADULT GETS 1.0 mmol/kg of K+.
FRUIT,MILK AND HONEY ARE RICH SOURCES.
� POTASSIUM DEPLETION : THE AUGMENTED POTASSIUM EXCRETION OF TRAUMA -
DEGREE OF TISSUE DAMAGE IS DIRECTLY PROPORTIONAL TO LOSS, IS GREATEST DURING THE FIRST 24 HRS AND LASTS FOR 3 OR 4 DAYS.
HYPOKALEMIA REVEALS AFTER 48 HRS.
HYPOKALEMIA
� SUDDEN HYPOKALEMIA : DIABETIC COMA, TREATED BY INSULIN AND PROLONGED INFUSION OF SALINE.
� GRADUAL HYPOKALEMIA : DIURETICS DIARRHOEA IBD VILLOUS TUMOURS EXTERNAL FISTULAE(GI)
CLINICAL FEATURES
� CLINICAL FEATURES : LISTLESSNESS,SLURRED SPEECH,MUSCULAR HYPOTONIA,DEPRESSED REFLEXES,ABDOMINAL DISTENTION(PARALYTIC ILEUS) RAPID SHALLOW RESPIRATION.
� DIAGNOSIS BY ECG : PROLONGED QT INTERVAL,DEPRESSION OF ST SEGMENT,FLATTENGING OR INVERSION OF T WAVE
TREATMENT
TREATMENT : ORAL – MILK,MEAT,FRUIT JUICES,HONEY POTASSIUM CHLORIDE 2G ORALLY 6TH HOURLY.
INTRAVENOUS : RAPID CORRECTION-DYSRHYTHMIAS AND CARDIAC ARREST.
40mmol Kcl to EACH 1 LITRE OF 5% D OR DNS OR 0.9% SALINE - 6 TO 8 HOURLY.
HYPERKALEMIA � HYPERKALEMIA : BRADYCARDIC CARDIAC ARREST
� MAJOR CAUSES : RENAL TUBULAR ACIDOSIS
ADDISON’S DISEASE, CONGESTIVE HEART FAILURE.
� DRUGS : DIGOXIN, AMILORIDE, SPIRINOLACTONE,
TRIMETHOPRIM, NSAIDS, CYCLOSPORINE.
TREATMENT 1. CALCIUM GLUCONATE 10 ml OF 10% SOLUTION OVER 2-3
MIN WHEN K+>6.5
2. INSULIN+GLUCOSE 10 units REGULAR IV+50% DEXTROSE
3. NAHCo3 : 90 mmol(2 ampules IV PUSH OVER 5 MIN)
4. KAYEXALATE+SORBITOL
ORAL 30G WITH 20% SORBITOL RECTAL
50G IN 200ml 20% SORBITAL ENEMA RETAIN 45 MIN
5. FUROSEMIDE : 20-40mg 1V PUSH
6. DIALYSIS
CALCIUM BALANCE
� CALCIUM : EXTRA CELLULAR CATION PLASMA CONCENTRATION OF 2.2-2.5mmol/L(8 to 10mg/dl) IT EXIST IN THREE FORMS 1. BOUND TO PROTIEN 2. FREE NON IONISED 3. FREE IONISED LAST FORM : NECESSARY COMPONENT FOR BLOOD COAGULATION AND FOR AFFECTING THE NEURO
MUSCULAR EXCITABILITY
HYPERCALCEMIA � HYPERCALCEMIA : Ca LEVELS>2.9mmol/L(>11.5mg/dl)
� CLINICAL FEATURES : FATIGUE, DEPRESSION, CONFUSION, ANOREXIA, NAUSEA,
CONSTIPATION, POLYURIA, ARRHYTHMIAS SEVERE HYPERCALCEMIA – 3.7 mmol/L(>15mg/dl) MEDICAL EMERGENCY – COMA AND CARDIAC ARREST
� CAUSES : PARATHYROID ADENOMAS, MEN SYNDROMES, MULTIPLE MYELOMAS,
METASTASES(BREAST Ca), LUNG AND KIDNEY MALIGNANCIES, VITAMIN D INTOXICATION.
BONES, STONES, ABDOMIAL GROANS AND PSYCHIC MOANS
TREATMENT : 1. HYDRATION WITH SALINE(6L/day)
2. FORCED DIURESIS-FUROSEMIDE 4-12hourly ALONG WITH AGGRESSIVE HYDRATION
3. BISPHOSPHONATES-PAMIDRONATE 30-90 mg IV OVER 4 HOURS
4. CALCITONIN-2-8 U/kg IV/IM 6-12 hrs
5. GLUCOCORTICOIDS - PREDINSONE 10-25mg qid
6. MITHRAMYCIN
7. DIALYSIS
HYPOCALCEMIA
� CLINICAL FEATURES : PERIPHERAL AND PERIORAL PARESTHESIA, MUSCLE
SPASMS, CARPOPEDAL SPASMS, LARYNGEAL SPASM, SEIZURES, RESPIRATORY ARREST. TETANY. TROUSSEAU’S SIGN, CHEVOSTEK’S SIGN
� CAUSES : BURNS, SEPSIS, ACUTE RENAL FAILURE, MASSIVE BLOOD
TRANSFUSIONS.
� TREATEMENT : 1. 10ml OF 10% Ca gluconate given over 10 min 2. CALCIUM GLUCONATE IV 20 – 50ml OVER 8 HRS
� HYPOPARATHYROIDISM : Ca+VITAMIN D OR CALCITRIOL
MAGNESIUM
INTRA CELLULAR CATION
NORMAL LEVELS – 0.7 – 0.9mmol/L.
20mmol MAGNESIUM SULPHATE ADDED TO 5% D OR NS SOLUTIONS TO TREAT HYPOMAGNESEMIA.
ACID BASE BALANCE
� PH NORMAL RANGE – 7.35 - 7.45
� PH LOW ACIDOSIS
� PH HIGH ALKALOSIS
� PO2 :-NORMAL VALUE - 80-110 mmHg
� PCO2 :-NORMAL VALUE - 35-45 mmHg
� HCO3 :-NORMAL VALUE - 25 mmol/L
PH
PCO2
HCO3
RESPIRATORY
ACIDOSIS
METABOLIC
ACIDOSIS
RESPIRATORY
ALKALOSIS
METABOLIC
ALKALOSIS
NORMAL RANGE OF PH 7.35-7.45
� PCO2 : PARTIAL PRESSURE OF CO2 IN THE BLOOD NORMAL VALUE
35-45mmHg or 4.1-5.6 K Pa � PO2 : PARTIAL PRESSURE OF OXYGEN IN THE BLOOD NORMAL
VALUE - 80-110mmHg or 10.5 – 14.5 KPa � STANDARD BICARBONATE : IS THE CONCENTRATION OF THE SERUM BICARBONATE
AFTER FULLY OXGENATED BLOOD HAS BEEN EQUILIBRATED WITH CO2 at 40mmHg at 380C
NORMAL LEVELS : 22-25mmol/Litre
ALKALOSIS
� METABOLIC ALKALOSIS : BASE EXCESS OR ACID DEFICIT 1. EXCESSIVE INGESTION OF ABSORBABLE ALKALI 2. LOSS OF ACID FROM STOMACH :VOMITING OR
ASPIRATION 3. CORTISONE EXCESS – CUSHING’S SYNDROME � COMPENSATION : A. RETENTION OF CO2 BY LUNGS B. EXCREATION OF BICARBONATE BASE BY THE
KIDNEYS(ALKALINE URINE)
CLINICAL FEATURES
� ALKALOSIS DUE TO LOSS OF ACID,MOST COMMON PYLORIC STENOSIS
� SEVERE ALKALOSIS : CHEYNE STOKES BREATHING WITH PERIODS OF APNOEA (5 TO 30seconds), TETANY.
� RENAL EPITHELIAL DAMAGE – RENAL INSUFFICIENCY.
� TREATMENT :CORRECT THE UNDERLYING CAUSE, ENCOURAGE HIGH URINARY OUTPUT.
� HYPOKALEMIC ALKALOSIS :VOMITING LEADS TO LOSS OF POTASSIUM & LOW SERUM K+ . K+ LEAVES THE CELL TO ENTER THE SERUM IN EXCHANGE FOR Na+ & H+ IONS WHICH CAUSE INTRACELLULAR ACIDOSIS.
� TREATMENT : CORRECT HYPOKALEMIA
IV FLUIDS + 40mmol/L OF KCL IF THE URINE OUTPUT IS ADEQUATE
MORE RAPID CORRECTION WITH ECG MONITERING
RESPIRATORY ALKALOSIS
� PCO2 IS BELOW 35 – 45 mmHg.
� EXCESSIVE PULMONARY VENTILATION.
� HYPER VENTILATION ON AN ANAESTHETIZED PATIENT, HIGH ALTITUDE, HYPER PYREXIA, HYPOTHALAMUS LESION, HYSTERIA.
� COMPENSATION : RENAL EXCREATION OF BICARBONATE.
� ANAESTHESIA ALKALOSIS :PALOR, FALL IN BP, RESPIRATORY ARREST.
� TREATMENT : INSUFFLATION OF CO2.
ACIDOSIS
�METABOLIC ACIDOSIS : EXCESS OF ACID OR DEFECIT OF BASE � INCREASE IN FIXED ACIDS : KETOACIDOSIS, DIABETES OR STARVATION, RENAL
INSUFFICIENCY. IN CARDIAC ARREST, INCREASED LACTIC AND PYRUVIC
ACIDS – ANAEROBIC TISSUE METABOLISM. ACUTE ACIDOSIS PH>7.1 � LOSS OF BASES : SUSTAINED DIARRHOEA, ULCERATIVE COLITIS,
GASTROCOLIC FISTULAE, HIGH INTENSTINAL FISTULAE.
� CLINICAL FEATURES : RAPID,DEEP,NOISY BREATHING. INCREASE IN PH STIMULATION OF
RESPIRATORY CENTRE HYPERPNOEA URINE IS STRONGLY AICIDIC � TREATMENT : 1) CORRECT TISSUE HYPOXIA AND TISSUE PERFUSION FIRST. 2) TREATMENT WITH BICARBONATE SOLUTIONS WILL CORRECT THE MEASURED ACIDOSIS BUT NOT THE PROBLEM ACUTE ACIDOSIS IN M.I. REQUIRES INFUSION OF 50mmol of 8.4% NaHCO3 SOLUTION.
RESPIRATORY ACIDOSIS
� PCO2 THE NORMAL RANGE. � IMPAIRED ALVEOLAR VENTILATION. � PULMONARY DISEASES LIKE CHRONIC BRONCHITIS, EMPHYSEMA ARE
EXAMPLES OF CHRONIC CAUSES � ACUTE CAUSES INCLUDE,CEREBRAL DISEASE,GUILLAINE – BARRE
SYNDROME,MYASTHENIA GRAVIS, CARDIOPULMONARY ARREST � CLINICAL FEATURES : CONFUSION, MYOCLONUS, PAPILLOEDEMA & WARM EXTREMETIES WITH
BOUNDING PULSE. � TREATMENT : TREAT THE UNDERLYING CAUSE. IMPROVE THE VENTILATION. � ACUTE RESPIRATORY ACIDOSIS :ENDO TRACHEAL INTUBATION
+MECHANICAL VENTILATION.
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